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  ON LINE APPLICATION FORM FOR SIMPLIFIED NON MEDICAL INSURANCE.

This is an Application for a single Life, Permanent or Term 20 Life Insurance Policy. Please fill out the application form below. We will email you your quotation along with instructions of the application process and any additional forms that are required. Please complete the below form with all of your details and when complete, click on the submit button. All fields are required. Put N/A (Not Applicable) if the questions do not apply.

First Name:
Initials:
Last Name:
Address:
Postcode:
Cell or Home Phone: (We need to call you to confirm your submission, Please put in a # that is accessible)
Email:
Age:
DOB (dd/mmm/yyyy): i.e (16/Jan/1968)
Place of Birth (Province or Country)
In Canada Since
Social Insurance Number
Are you in Good Health? Yes No
In the last 12 Months have you used tobacco in any form whatsoever, including nicotine or tobacco products (Gum, patches, electronic cigarettes etc ? Yes No
Have you ever smoked Tobacco? Yes No
If yes.. When did you give up?
Gender: Male Female
Language: English French
Are you a resident of Canada for Income Tax Purposes? Yes No
If you are a resident of The U.S for Income Tax purposes, Please provide your (TIN) or SSN Number
What is your Citizenship?
Coverage Required:
Coverage Amount Required? (min $10,000, max $300,000) $
Main Beneficiary
Beneficiary DOB
Relationship to Beneficiary
  DECLARATION OF INSURABILITY
Deferred : Maximum of $50,000 - Permanent to age 100 protection Only. If death occurs in the first 2 years of the policy, other than accidental death, ONLY the premiums plus 3% interest will be payable to the beneficiary STEP ONE
1) In your lifetime, have you ever been diagnosed, followed, hospitalized and/or treated for any of the following conditions:
a. Acquired immunodeficiency syndrome (AIDS) or tested positive for the human immunodeficiency virus (HIV)? Yes No
b. Heart failure? Yes No
c. Cystic fibrosis, Alzheimer’s disease, dementia, Huntington’s chorea, Parkinson’s disease, amyotrophic lateral sclerosis (Lou Gehrig’s disease), muscular dystrophy, myotonic dystrophy, or any form of ataxia? Yes No
d. For persons less than 18 years old, type 1 diabetes, cerebral palsy, congenital heart disease, Down’s syndrome or autism spectrum disorder (ASD)? Yes No
2) Within the last three (3) years, have you been diagnosed or treated for leukemia, lymphoma, malignant tumour or any form of cancer (other than basal cell carcinoma)? Yes No
3) Are you presently:
a. Hospitalized or in a nursing facility including a centre or a home for individuals with reduced autonomy, bedridden or wheelchair bound?b. Heart failure? Yes No
b. Undergoing or waiting for an investigation for diagnostic purposes? Yes No
  STEP 2
Deferred Plus : Maximum of $200,000 - Permanent to age 100 or Term 20 protection. If death occurs in the first 2 years of the policy, other than accidental death, ONLY the premiums plus 3% interest will be payable to the beneficiary
1) In your lifetime:
a. Have you ever had an amputation as a result of disease? Yes No
b. Have you ever suffered from hepatitis C or any type of chronic hepatitis? Yes No
2) Within the last five (5) years:
a. Have you received an organ transplant or a bone marrow transplant or were you advised to do so due to your condition? Yes No
b. Have you used any hard drugs except as prescribed by a physician or have you used methadone prescribed by a physician or not? Yes No
3) Within the last three (3) years, have you been diagnosed, followed, hospitalized and/or treated for any of the following conditions:
a. Heart attack, cerebrovascular disease (stroke), coronary artery disease, angina, cardiac bypass surgery, angioplasty or peripheral vascular disease (excluding varicose veins and superficial phlebitis)? Yes No
b. Chronic liver disease (including cirrhosis and fibrosis), chronic kidney disease or chronic respiratory disease that required the administration of oxygen (excluding sleep apnea)? Yes No
4) Within the last twelve (12) months:
a. With regards to depression or any mental or nervous disorder
I. Have you been hospitalized? Yes No
II. Has your medication been changed (dosage or addition of another medication or replacement of medication)? Yes No
III. Have you ceased your medication without being advised by your doctor to do so? Yes No
b. Have you undergone a surgery for an aneurysm or are you awaiting such surgery? Yes No
c. Has your medication for diabetes or high blood pressure been changed (dosage or addition of another medication or of insulin)? Yes No
What is Your Height? (ft)
What is Your Weight? (lbs)
  STEP THREE
Immediate : Maximum of $200,000 - Permanent to age 100 or Term 20 protection. Payment upon death is Immediate  
1) Within the last two (2) years, have you had an application for life insurance declined or postponed with any company other than iA Financial Group or iA Excellence? Yes No
STEP FOUR
Immediate Plus : Maximum of $300,000 - Permanent to age 100 or Term 20 protection. Payment upon death is Immediate  
1) Within the last five (5) years, have you been diagnosed, followed, hospitalized and/or treated for any of the following conditions:
a. Heart attack, cerebrovascular disease (stroke), coronary artery disease, angina, cardiac bypass surgery, angioplasty or peripheral vascular disease? Yes No
b. Heart murmur or transient ischemic attack? Yes No
c. Leukemia, lymphoma, malignant tumour or any form of cancer (other than basal cell carcinoma)? Yes No
d. Any form of epilepsy or seizures? Yes No
2) Within the last five (5) years, have you been hospitalized for any heart rhythm disorder? Yes No
3) Within the last five (5) years, have you been advised to reduce your alcohol or drug consumption or been treated for alcohol or drug abuse or have you joined a support group for an alcohol or drug problem? Yes No
4) Within the last twelve (12) months:
a. Have you been hospitalized for chest pain? Yes No
b. Has your weight decreased by 40 lbs or more (excluding after childbirth)? Yes No
c. Has your driver’s license been suspended or is it currently suspended? Yes No
5) Within the next two (2) years:
a. Will your situation require you to travel to high-risk regions or regions of conflict or war?? Yes No
b. Do you intend to reside outside Canada or the USA for at least six (6) months? Yes No
6) Family history:
Has any member of your immediate family (father, mother, brothers or sisters) been diagnosed with any of the following conditions:
a. Huntington’s disease or polycystic kidney disease before age 60? Yes No
b. For persons less than 3 years old, cystic fibrosis? Yes No
Mode of Payment once approved. (Monthly, Annually)